Why more doctors are not the answer to India’s health crisis

India faces an acute shortage of doctors and needs to desperately ramp up the output from medical colleges — that’s the refrain of those arguing we need every kind of medical college we can have. The report prepared by a three-member committee of the Niti Aayog uses the same logic to push for allowing for-profit entities to set up medical colleges.Rema Nagarajan | TNN | September 18, 2016, 08:35 IST

It’s rural areas and govt hospitals that need more medicos, and there’s no evidence to suggest that graduates from for-profit colleges will bridge this gap

India faces an acute shortage of doctors and needs to desperately ramp up the output from medical colleges — that’s the refrain of those arguing we need every kind of medical college we can have. The report prepared by a three-member committee of the Niti Aayog uses the same logic to push for allowing for-profit entities to set up medical colleges. But is this sound logic? Will more doctors mean better healthcare for India’s 1.3 billion? A closer look at the facts raises serious doubts.

The shortage is more acute for doctors willing to work in the rural areas where almost 70% of Indians live, or one who will work in government hospitals.

Increasing medical seats in medical colleges can’t help address this shortage. Will city kids trained in technology-intensive settings and metropolitan tertiary care centres ever work in rural areas? Will these doctors understand the health problems of the rural populace? These questions appear to be ignored in the rush to open private medical colleges.

According to a WHO report on India’s health workforce, based on the 2001 census, the number of doctors with actual medical qualifications was 2.7 lakh, 82.6% of them in urban areas. By rough estimates, India has over 9 lakh doctors now for a population of about 1.3 billion, a ratio of one doctor for roughly every 1,450 people against the WHO recommended norm of one per 1,000. In 2011, 31% of Indians lived in urban areas. Assume it’s now a third of the total or about 430 million. Assume also, that only 70% of the doctors now are in urban areas. That would still mean 6.3 lakh doctors in urban areas against the need for 4.3 lakh. That’s an extra 2 lakh or nearly 50% more.

Yet, more than a quarter of CGHS posts of general duty medical officers (381 out of 1,383), all in urban areas, were lying vacant last year, health minister JP Nadda recently told the Lok Sabha. Hundreds of posts are lying vacant in top government hospitals including AIIMS. If the huge surplus of doctors in urban areas does not result in filling up these posts even in the Capital, obviously, adding to this surplus is not the solution.

The reasons for these vacancies listed by Nadda included low rates of joining of those recruited and non-availability of eligible SC/ST candidates for reserved posts. The low rate of joining could be due to poor working conditions or inadequate professional incentives. The non-availability of SC/ST candidates certainly can’t be ameliorated by more private colleges with no caste reservation. If anything, it could exacerbate the problem.

In contrast, in rural areas there would currently be at best 2.7 lakh doctors to serve close to 870 million people, or one doctor for about 3,200 people. To meet the WHO norm, rural India needs 6 lakh more doctors. More than half of all MBBS seats are now in private colleges. It’s irrational to expect that more such colleges will bridge this gap.

That’s not to suggest products of government colleges are eager to serve in rural areas. More than 65% of medical seats were in government colleges in 2000. Yet, rural areas had less than 18% of doctors with proper qualifications in 2001. Obviously, churning out doctors from government colleges, training them in urban tertiary care centres is unlikely to address the acute rural shortage.

How then is this shortage to be addressed? Among possible solutions could be a quota for rural students who might be more inclined to work there or a policy of identifying students with a stronger sense of public service. But such ideas do not seem to form a part of any discussion.

India’s high infant mortality rate (IMR) and maternal mortality rate (MMR) are also cited to argue for a rapid expansion of medical education. But that’s just not logical. Most maternal deaths happen among poor and illiterate women. Research unambiguously shows that the bulk of maternal deaths can be avoided by improving socio-economic status, level of education, nutrition, antenatal care, early referral, and quick and well equipped transport facilities. None of these are dependent on doctors.

More than half of IMR is neonatal mortality or death within the first 28 days of life. Prematurity, low birth weight and neonatal infections account for the bulk of these. Breastfeeding, safe water and increased immunisation coverage can help better than doctors in brining down IMR. Incidentally, Delhi, with its high concentration of doctors, also has the highest IMR among metros (40) while Manipur, Meghalaya, Sikkim and Tripura, where doctors are scarce, have IMR ranging from 30 to 22.

In short, there’s a lot more to tackling India’s biggest health issues than simply increasing the output of doctors. The experience of Sri Lanka, Thailand and Iran also shows that much better health outcomes are possible even in developing countries with fewer than one doctor for every 1,000 people.

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